- Validated assessment tools should be used to assess for delirium
- Hepatic encephalopathy is a major contributor to delirium/agitation and must be considered as the diagnosis of exclusion in any patient presenting with confusion.
- Before using this algorithm, it is essential to distinguish these two patients*:
- Advanced cirrhosis not at the end of life where confusion may be due to Hepatic encephalopathy – confusion CAN recover with Hepatic encephalopathy therapy, (see Hepatic encephalopathy page). Some of these patients may still be candidates for liver transplantation if it is in keeping with their goals of care. Hepatic encephalopathy MUST be ruled out before using this algorithm.
- Advanced cirrhosis at the end of life (last weeks to days) with delirium/agitation who are not candidates for liver transplantation and do not want further management for their Hepatic encephalopathy. Can use the algorithm.
*This distinction can be challenging. A trial of lactulose can be helpful. Ask for advice from a liver specialist if guidance is required.
- In addition to Hepatic Encephalopathy, consider additional workup to identify and manage reversible causes of delirium
- Even at end-of-life, if it is in keeping with the patient’s goals of care, therapy with lactulose and/or rifaximin can be continued while the patient is able to swallow.
Consider contributing causes for delirium and investigate & treat if in keeping with the patient’s goals of care.
Consider Non-pharmacological therapy in addition to PRN pharmacological therapies in patients where delirium and associated symptoms (restlessness, agitation, perceptual disturbances – hallucinations, delusions) are having a significant impact on the patient’s quality of life and ability to function.
Always consider degree of sedation when selecting a medication. It is critical to assess the patient’s preference/tolerance of sleepiness, especially if regular doses are required.
There are only a few instances where benzodiazepines, e.g. lorazepam, should be the first choice as an alternative to or alongside the below mentioned neuroleptic medications
- Alcohol withdrawal (see CCAB Alcoholic hepatitis page)
- Benzodiazepine withdrawal
- Long-term benzodiazepine use
If symptoms persist despite the management above, review medical status and goals of care.
Stop Haloperidol or other Neuroleptic
|Medication:||Recommended Dose||Additional information|
6.5 mg-12.5 mg PO/SC q8 h ATC AND q 1h PRN
-Least risk of seizures.
We gratefully acknowledge the Physician Learning Program for their design assistance.
This section was adapted from content using the following evidence based resources in combination with expert consensus. The presented information is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to determine a patient’s care.
Authors (Alphabetical): Amanda Brisebois, Sarah Burton-Macleod, Ingrid DeKock , Martin Labrie, Noush Mirhosseini, Mino Mitri, Kinjal Patel, Aynharan Sinnarajah, Puneeta Tandon
Thank you to pharmacists Omer Ghutmy and Meghan Mior for their help with reviewing these pages.
- Confusion Assessment Method (CAM):
- Hepatic Encephalopathy:
- Opioid Toxicity:
- Davison SN on behalf of the Kidney Supportive Care Research Group. Conservative Kidney Management Pathway; Available from: https//:www.CKMcare.com.
- Palliative sedation guidelines: http://www.cspcp.ca/wp-content/uploads/2017/11/Palliative-Sedation-Edmonton-Final-Dec-2015.pdf
- Palliative care tips/delirium in patients with advanced cancer and those who are imminently dying: https://albertahealthservices.ca/info/Page16872.aspx
- Agar, M. et. al. Efficacy of Oral Risperidone, Haloperidol, or Placebo for Symptoms of Delirium Among Patients in Palliative Care: A Randomized Clinical Trial. JAMA Internal Medicine 177(1): 34-42. PMID: 27918778
- Bush, SH., Tierney, S., and Lawlor, PG. Clinical Assessment and Management of Delirium in the Palliative Care Setting. 2017. Drugs 77:1623-1643. PMID: 28864877
- Bush, SH., et. al. Treating an Established Episode of Delirium in Palliative Care: Expert Opinion and Review of the Current Evidence Base with Recommendations for Future Development. 2014. JPSM 48(2): 231-248. PMID: 24480529
- De la Cruz, M., et. al. Increased Symptom expression among Patients with Delirium Admitted to an Acute Palliative Care Unit. 2017. Journal of Palliative Medicine. 20(6): 638-641. PMID: 28157431
- Hui, D. Benzodiazepines for agitation in patients with delirium: selecting the right patient, right time, and right indication. 2018.Curr Opin Support Palliat Care 12: 489-494. PMID: 30239384
- Hui, D. et. al. Effect of Lorazepam with Haloperidol vs Haloperidol alone on Agitated Delirium in Patients With advanced Cancer Receiving Palliative Care: A Randomized Clinical Trial. 2017. JAMA. 318(11): 1047-1056. PMID: 28975307
- Lewis J. H., Stine J. G. Review article: prescribing medications in patients with cirrhosis – a practical guide. Aliment Pharmacol Ther 2013; 37: 1132–1156. PMID: 23638982
- Oh, E. et. al. Delirium in Older Persons: Advances in Diagnosis and Treatment. 2017. JAMA 318(12): 1161-1174. PMID: 28973626